MEDICARE: DEPARTMENT OF MENTAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083732168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPARTMENT OF MENTAL HEALTH

Provider Business Mailing Address
First Line	:	25 STANIFORD ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02114-2503
Country	:	US
Telephone Number	:	617-626-8040
Fax Number	:	617-626-8295

Provider Business Practice Location Address
First Line	:	BOSTON UNIVERSITY - FULLER IRTP
Second Line	:	85 E NEWTON ST FL 6
City	:	BOSTON
State	:	MA
Zip	:	02118-2340
Country	:	US
Telephone Number	:	617-414-2005
Fax Number	:	617-414-2101

Authorized Official
Title or Position	:	ASST DIRECTOR OF NON-INST REIMBURSE
Name	:	MR. PAUL SCOPA
Credential	:
Telephone Number	:	617-886-8089

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	08/22/2020

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Directions to “DEPARTMENT OF MENTAL HEALTH ” Practice Location

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